Heavy Periods (Menorrhagia)

What is Heavy Periods?

Heavy periods, or heavy menstrual bleeding, is bleeding of more than about 80 milliliters (roughly 5 tablespoons) per period or bleeding heavy enough to interfere with your quality of life.^[1] It is common, affecting roughly 2 to 5 in 10 women of reproductive age.^[2]

Common symptoms

The main symptom is bleeding that is heavier or longer than you consider normal. Because blood loss is hard to measure at home, doctors often rely on how it affects you, such as having to change products very often or limiting your activities.^[1]

Heavy bleeding can lead to iron deficiency and, in more severe cases, iron deficiency anemia. Both can cause fatigue and reduced quality of life, and they are often overlooked.^[3]

Causes and risk factors

Doctors group the causes of abnormal uterine bleeding as structural (polyps, adenomyosis, fibroids, and precancerous or cancerous changes) and nonstructural (bleeding disorders, ovulation problems, problems of the uterine lining, and medicines).^{[1, 4]} Fibroids and adenomyosis are two common structural causes.^{[5, 6]}

Bleeding is most likely to be irregular around the start of periods and around perimenopause.^[1] In many women no cause is found, and the condition is called idiopathic heavy menstrual bleeding.^[7]

How it is diagnosed and treated conventionally

Evaluation starts with a detailed history and physical examination. It may include blood tests, imaging, and sampling of the uterine lining when indicated.^[1] Treatment aims at the cause, and the choice depends on your age, whether you want a pregnancy, and your preferences.^[2]

A Cochrane overview found that a levonorgestrel-releasing intrauterine system reduced menstrual blood loss the most among first-line treatments. Antifibrinolytic medicines such as tranexamic acid probably reduce blood loss, as do long-cycle progestogens, and anti-inflammatory drugs reduce it slightly. For those who need more, endometrial ablation and hysterectomy are among the second-line options.^[2] Tranexamic acid was more effective than placebo, and than the herbal preparations compared with it, in a Cochrane review.^[8] Iron deficiency should also be treated.^[3]

Why Heavy Periods calls for a whole-person approach

Heavy bleeding has more than one possible cause, and more than one effect. The cause may be in the uterus itself, in hormones, or in blood clotting, and the effects reach energy, mood, work and school.^{[1, 3]}

Complementary care can support general health and comfort while the cause is being treated. It does not take the place of finding out why the bleeding is heavy.

Structural causes

Fibroids are the most common benign growths of the uterus. They are driven mainly by estrogen and often cause heavy bleeding, pelvic pressure and anemia.^[5] In adenomyosis, tissue like the uterine lining grows within the muscle wall, and heavy bleeding and painful periods are its most common symptoms.^[6]

Hormones and ovulation

When ovulation does not occur regularly, the lining of the uterus can build up and shed unpredictably. Ovulation problems are one of the nonstructural causes doctors look for.^[1]

Blood clotting

Bleeding disorders are another recognized cause and are looked for in the evaluation.^[1] This matters for herbal care, since some herbs affect bleeding.

Iron stores and fatigue

Iron deficiency is a major consequence of heavy periods, and it affects quality of life every day, not only during bleeding.^[3] Checking and replacing iron is part of good medical care.

Acupuncture for Heavy Periods

What the research shows

We found no clinical trials of acupuncture for heavy menstrual bleeding. A systematic review of controlled trials of acupuncture for women's reproductive health found none in menorrhagia that met its inclusion criteria.^[9] A later overview found that acupuncture for menstrual complaints other than period pain and menopause symptoms is under-studied, and that evidence on those is often based on single studies.^[10]

Acupuncture for uterine fibroids, a common cause, also lacks trials. A Cochrane review found no eligible randomized controlled trials and concluded that its effectiveness remains uncertain.^[11]

For period pain, which often goes along with heavy periods, small studies suggest acupuncture may help, but the trials were few and of variable quality.^[9]

How acupuncture may work

We found no research on how acupuncture would act on heavy menstrual bleeding. Claims that it regulates the uterine lining or hormones have not been tested in trials for this condition.

What treatment involves

Acupuncture uses fine, sterile, single-use needles placed at points on the body, usually left in place for about 20 to 40 minutes. A course of several visits is followed by reassessment. If used, it is for general support such as comfort and stress, not to stop bleeding.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or a flare at the needle site, and serious events occurred in about 1 in 10,000 patients.^[12] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Heavy Periods

The Ayurvedic view

In Ayurveda, heavy menstrual bleeding is described under the name Asrigdara.^[13] Traditionally it is linked to aggravated Pitta, the principle associated with heat, sometimes with Vata or Kapha involvement, and treatment is chosen for the individual. These are traditional categories, not biomedical diagnoses.

Therapies that may be used

Care traditionally combines:

• Diet and routine intended to cool and calm Pitta, such as regular meals and enough rest
• Herbs such as Ashoka (Saraca asoca) and formulas that contain it, prescribed individually^[13]
• Stress-reducing practices such as gentle yoga and breathing exercises

Panchakarma is not appropriate during pregnancy, acute illness, frailty, anemia, or while bleeding is heavy. Heavy bleeding needs a medical evaluation before any Ayurvedic care.

What the research shows

The research on Ayurveda for heavy periods is very limited. We found one open-label study of an Ashoka-based syrup in 228 women with heavy bleeding. It reported lower blood loss scores after 90 days, but it had no placebo or comparison group, so it cannot show that the syrup caused the change.^[13] We found no placebo-controlled trials or systematic reviews of Ayurvedic treatment for the condition.

Herbal medicine for Heavy Periods

Herbs and formulas that have been studied

Several herbs have been tested in small trials for heavy periods. They include ginger, myrtle fruit syrup, pomegranate (Punica granatum) flower, shepherd's purse (Capsella bursa-pastoris) and frankincense (Boswellia).^{[7, 14, 15, 16]} Chinese herbal formulas have also been studied for dysfunctional uterine bleeding, an older term for bleeding without a structural cause.^[17]

What the research shows

The evidence is limited. A systematic review found only three randomized trials of herbal medicine for idiopathic heavy bleeding. Ginger capsules and myrtle fruit syrup reduced blood loss more than placebo, and pomegranate flower capsules performed about as well as tranexamic acid. The authors called for better trials.^[7]

In a placebo-controlled trial of 92 young women, ginger lowered blood loss more than placebo.^[14] In a trial of 84 women, shepherd's purse added to mefenamic acid reduced bleeding more than mefenamic acid with placebo.^[15] In 102 women taking ibuprofen, adding ginger or frankincense shortened the bleeding, but the amount of bleeding fell in all groups, including placebo, with no difference between them.^[16]

These trials were small and short. A Cochrane review also found that tranexamic acid worked better than the two herbal preparations it was compared with.^[8] A meta-analysis of four trials of Chinese herbs for dysfunctional uterine bleeding found poor method quality in most and could not judge efficacy because none compared the herbs with placebo or no treatment.^[17] For fibroids, a Cochrane review of 21 trials found the evidence neither supported nor refuted herbal preparations.^[18]

Safety and herb-drug interactions

Herbs are active substances and are prescribed individually by a qualified practitioner. Because the condition involves bleeding, this matters. Case reports describe bleeding or bruising when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen, ginger, ginkgo, garlic and Boswellia.^[19] Tell us if you take blood thinners, hormonal treatments, tranexamic acid or any other medicine.

Herbs traditionally used to move blood are not appropriate during heavy bleeding or pregnancy. In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic, so herbs should come from tested sources.^[20] Tell us if you have liver or kidney disease or surgery planned.

Transdermal medication therapy, an herbal preparation applied to the skin, is also offered, but we found no studies of it for heavy periods.

Translating traditional medicine into modern biological language

The comparisons here are interpretation, not equivalence. Chinese medicine describes heavy bleeding with patterns such as qi failing to hold the blood, heat in the blood, and blood stasis, and Ayurveda describes aggravated Pitta in Asrigdara. Researchers studying the same problem instead look at structural causes, ovulation, the uterine lining, clotting and iron status.^[1]

The trials we reviewed did not test how the herbs studied for heavy periods might act on bleeding. No study has shown that a pattern or dosha corresponds to a specific biological process.

How this care fits with your medical care

Complementary care for heavy periods works alongside your gynecologist or primary care physician. Keep your medical team, continue your prescribed treatment such as tranexamic acid, hormonal therapy or iron, and do not stop or change any medicine without your prescriber. We do not diagnose the cause of heavy bleeding, so new or worsening bleeding should be medically evaluated first.

Please bring your diagnosis, ultrasound and blood test results including hemoglobin and iron, a full list of medicines and supplements, and notes on your bleeding pattern.

When to seek urgent medical care

Heavy bleeding can sometimes become an emergency, so know the warning signs.

• Soaking through a pad or tampon every hour for two or more hours in a row
• Dizziness, fainting, a racing heart or shortness of breath
• Heavy bleeding during pregnancy or after menopause
• Severe pelvic pain or fever with heavy bleeding
• Passing very large clots repeatedly
• Pale skin, new weakness or marked tiredness suggesting anemia

For emergencies, call 911 or go to the nearest emergency department.